Imaging transient ischaemic attack with diffusion weighted magnetic resonance imaging

doi:10.1136/bmj.c2215

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Adam Wallis, specialty registrar in clinical radiology1,
Tim Saunders, consultant radiologist2

¹Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW
²Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, Wiltshire SN3 6BB

Correspondence to: A Wallis aw7823{at}hotmail.com

Transient ischaemic attack can be difficult to diagnose clinically. This article guides you through the radiological options available and highlights the role of diffusion weighted magnetic resonance imaging in detecting acute ischaemia

Learning points

The ABCD² score is a useful tool for triaging patients with suspected transient ischaemic attack (TIA) for timely imaging, and for predicting future outcome
Diffusion weighted magnetic resonance imaging is the most sensitive and specific imaging modality in the detection of acute ischaemia
TIA and minor stroke can be difficult to diagnose clinically, and magnetic resonance imaging with diffusion weighted imaging can help exclude mimics or confirm the diagnosis
Patients with clinical TIA and positive diffusion weighted imaging are most at risk of subsequent completed stroke
Patients with clinical TIA and negative diffusion weighted imaging are at risk of subsequent TIA

The patient

A 72 year old man with a history of diabetes and hypertension presented to his general practitioner with a transient history of slurred speech and left sided numbness earlier the same day. Symptoms had resolved over four hours, and on examination he had no focal neurological signs. His blood pressure measured 156/84 mm Hg and heart sounds and electrocardiography were normal. The patient was started on 300 mg aspirin daily and referred to the transient ischaemic attack (TIA) clinic.

What are the next investigations?

TIA is defined as any focal neurological ischaemic event with symptoms lasting less than 24 hours, but in practice most last less than one hour. Abrupt focal symptoms that are maximal at onset and are compatible with ischaemia in a single vascular territory are good diagnostic indicators of a TIA or minor stroke rather than a mimic. The estimated risk of completed stroke after a TIA is 8-12% at one week and 11-15% at one month.1 It is now recognised that a TIA needs …